Mobile Trauma Therapy Agency Referral Form – Community Health Council of Lebanon County

Name of client *

Age of client *

Are you referring a minor? *

Yes
No

Name of Parent

Client Phone *

Client Email *

Client Gender *

Male
Female
Other/Decline to Answer

Client Race/Ethnicity *

Is it ok to leave a detailed message on client's phone or email? *

Yes
No

Do you have your client's permission to submit this referral? *

Yes
No

Why are you referring for mobile trauma therapy?

Referral Source Contact Information

Name *

Agency *

Phone *

Email *

Please note: Webforms are not considered confidential communication. Information on this form will be saved on the Community Health Council’s website, and will be sent to both the Director and the Connected Together Coordinator. If confidentiality is a concern, please call Caitlin Lockard at 717-270-6972 x360 to make your referral.